Predictors of medical staff’s knowledge, attitudes and behavior of dysphagia assessment: A cross-sectional study

Purpose This study aimed to explore the predictors of medical staff’s Knowledge, Attitudes and Behavior of dysphagia assessment, to provide reference suggestions for constructing the training program and improving the rate of dysphagia assessment. Methods This study was a cross-sectional study. A total of 353 nurses and doctors from four provinces (Guangdong, Hunan, Guangxi, and Shaanxi) who were selected by convenience sampling and invited to complete the questionnaire through WeChat, DingTalk, and Tencent instant messenger from May 23 to 31, 2022. A self-reported questionnaire was used to assess participants’ Knowledge, Attitude and Behavior regarding dysphagia assessment. Participants’ sociodemographic, training, and nursing experience were measured using the general information sheet and analyzed as potential predictors of medical staff’s Knowledge, Attitudes and Behavior of dysphagia assessment. A multiple linear regression model was used to identify the predictors. Results The mean scores for Knowledge, Attitudes and Behavior of dysphagia assessments were (15.3±2.7), (35.9±4.9) and (41.4±14.4) respectively. Knowledge and Behavior of medical staff were medium, and attitude was positive. Multiple linear regression results indicated that experience in nursing patients with dysphagia, related training for dysphagia, working years in the field of dysphagia related diseases, specialized training (geriatric, swallowing and rehabilitation) and department (Neurology, Rehabilitation, Geriatrics) were significant predictors of Behavior, accounting for 31.5% of the variance. Working years in the field of dysphagia related diseases, department (Neurology, Rehabilitation, Geriatrics) and title were significant predictors of medical staff’s knowledge, accounting for 7.8% of variance. Education, experience in nursing patients with dysphagia, department (Neurology, Rehabilitation, Geriatrics) and related training for dysphagia were significant predictors of medical staff’s attitude, accounting for 12.9% of variance. Conclusions The study findings implied that nursing experience, training, and work for patients with swallowing disorders could have positive effects on the Knowledge, Attitudes and Behavior of medical staff regarding dysphagia assessment. Hospital administrators should provide relevant resources, such as videos of dysphagia assessment, training centers for the assessment of dysphagia, and swallowing specialist nurses.

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.Dysphagia occurs in 37-78% of patients after stroke [2][3][4] .Dysphagia may be defined as the partial or complete inability to prepare and move a bolus of food, fluids, or saliva efficiently and safely from the mouth to the esophagus and stomach [5] .Oropharyngeal Dysphagia(OD) is prevalent in the elderly and people with complex medical conditions; for example, aspiration pneumonia is caused by silent aspiration in stroke patients, resulting in considerable medical psychosocial consequences, reduced quality of life, and affects the prognosis of patients.

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Prevalence estimates for OD determined by a meta-analysis were 36.5% in hospital settings, 42.5% in rehabilitation settings, and 50.2% in nursing homes [6] .The type and combination of screening and assessment methods used to determine the prevalence of OD varies.More than half of the studies reported OD prevalence data using screening and clinical non-instrumental assessment methods or tools that were either designed by the authors for the purpose of the study or modified versions of published tools, thus lacking information on diagnostic performance and psychometric properties [7][8][9] .However, instrumental assessments require specialized training and equipment because of feasibility (e.g., availability, ease of administration).Screening and clinical non-instrumental assessments are the natural first choice for estimating the prevalence of OD [10] .Speech-language pathologists(SLPs) in medical settings are responsible for evaluating patient feeding and swallowing.Once an evaluation is completed, nursing staff typically provide hands-on care and supervision of meals [11] .One study's results suggest that both SLP and nursing training programs should include more evidence from multidisciplinary sources, specifically the medical literature, to improve the knowledge base of clinicians providing care to residents with swallowing disorders [12] .One study evaluated nurses' barriers to compliance with dysphagia measures.The study demonstrated that a knowledge deficit was an important barrier in dysphagia care for nurses, and this can be improved with short training [13] .Studies on the factors contributing to barriers to the assessment of dysphagia are lacking.We aimed to explore factors contributing to barriers to the assessment of dysphagia, develop training resources, and improve health outcomes by investigating the predictors of medical staff's Knowledge, Attitudes and Behavior of dysphagia assessment.

Design and Participants
This was a cross-sectional study.A total of 430 nurses and doctors in four provinces (Guangdong Province, Hunan Province, Guangxi Province, and Shaanxi Province) were selected by convenience sampling.The inclusion criteria were as follows: (a) Chinese RNs, doctors, or therapists with a medical background, (b) working at the hospital for more than 3 months, and (c) not internship.
Based on the suggestion of Hair, Black, Babin, and Anderson [14] , a ratio of 10 to 20 participants for each parameter was required for structural equation modeling.Thus, 220-440 participants were followed by a calculation of a 15% attrition rate, which resulted in a total sample of 430 participants in this study.An anonymous survey was conducted with permission from the research ethics committee of the participating hospital.Participants were informed about the aims and content of the study and the importance of enrollment.A total of 430 nurses and doctors completed the questionnaire, corresponding to a response rate of 100%.The valid questionnaire was 82.09%, and invalid questionnaires were eliminated.The criteria for eliminating invalid questionnaires were (a) incomplete questionnaires, (b) a questionnaire with incorrect content, (c) logically contradictory questionnaires, and (d) a questionnaire that completed less than 300 s and more than 3600 s.

Ethical statements
This study was approved by Ethics Committee of Longgang Central Hospital of Shenzhen(No.2022ECPJ101).The first part of the questionnaire mainly included informed consent, participants will read the informed consent at first, if they agree to participate in the study they will chose "I agree" to complete the following survey.The questionnaire survey was anonymous and personal information was not disclosed.

Research instruments
The following instrument were used to measure the outcomes of this study.The general information sheet.Demographic characteristics were measured using the general information sheet, which includes 11 items: province, hospital level and type, department, position, title, working years in the field of dysphagia-related diseases, education, experience of nursing patients with dysphagia, related training for dysphagia, specialized training in geriatric, swallowing, and rehabilitation.
Questionnaire on medical staff's Knowledge, Attitudes and Behavior of dysphagia assessment.Before the study, I obtained the consent of the author of the original questionnaire to modify the questionnaire.This questionnaire was revised based on the existing questionnaires designed by Dr. Dong Xiaofang [15] and Master Ma Keke [16] from The First Affiliated Hospital of Zhengzhou University.The KAB was shortened for Knowledge, Attitudes and Behavior.The MS-KAB-DA was shortened for the Questionnaire of Medical staff's Knowledge, Attitudes, and Behavior of dysphagia assessment, which is composed of three specific domains: Knowledge, Attitude(eight items), and behavior (13 items).The knowledge domain is composed of 25 items, including 17 True or False items(KR-20=0.760),four single-choice items, and four multiple-choice items.True or false items and single-choice items scored 1 for each correct choice and 0 for the wrong choice.Multiple choice items scored 0.2 for each correct choice and 0 for wrong choice.If a multiple-choice item had three correct choices that could score 0.6 maximally, but score 0 when the wrong choice was selected or the correct and wrong choices were selected simultaneously.Higher scores indicate higher cognitive levels.The total full knowledge score was 24.4.
Respondents were asked about their Attitude and Behavior to score using a 5-point scale, ranging from "strongly agreed" to "strongly disagreed" and "the most frequently" to "the least frequently.Higher scores indicated higher willingness and practice levels.The total full scores of Attitude and Behavior were 40 and 65, respectively.The questionnaire demonstrated good reliability and construct validity; the reported Cronbach's α coefficient was 0.832-0.879,and the content validity was 0.751 [15][16] .Internal consistency estimates were shown to have acceptable reliability for the questionnaire before the survey (Cronbach's alpha=0.865).

Data collection and Analysis
This study was approved by the ethics committee of the study hospital.Data were collected on May 23-31, 2022.All participants were invited to complete the questionnaire through WeChat, DingTalk, and Tencent QQ from May 23 to May 31, 2022.A professional questionnaire survey platform which provides functions equivalent to Amazon Mechanical Turk called "Wenjuan Xing" was used to investigate.The researcher sent the questionnaire through WeChat, DingTalk, and Tencent QQ to colleagues and classmates to fill in and asked them to forward the questionnaire to their colleagues.Data were analyzed using SPSS for Windows, version 23.Statistical significance was set at p < 0.05.The findings were summarized using descriptive statistics, univariate analysis, and dummy multiple regression analysis.The data were normally distributed, as assessed by skewness and kurtosis tests.Descriptive statistics ( e.g., mean, SD or n, %) were used to summarize the study variables.Univariate analysis (independent-samples t-test and one-way analysis of variance for categorical independent variables) was performed to explore the potential predictors of medical staff KAB for dysphagia assessment.A comparison analysis was conducted to analyze the differences in medical staff's KAB for dysphagia assessment among Guangdong Province, Hunan Province, Guangxi Province, and Shaanxi Province.

Characteristics of the Participants
A total of 430 nurses and doctors were enrolled, of which 353 nurses and doctors were valid.Clinical nurses, clinicians, and managers accounted for 66.29%, 19.26%, and 9.63%, respectively.Of the included hospitals, 81.02% were tertiary hospitals.Other characteristics, such as department, medical staff work, and learning experience, are summarized in Table 1.

KAB scores and scoring rate
Means and their scoring rates of the measurement outcome are listed in Table 2.The knowledge and behavior scores were medium, but the attitude scores were high.

KAB Differences in 4 province
As seen in Table 3, medical staff in Shaanxi Province were more willing to assess dysphagia and were evaluated more frequently.

Univariate analysis
KAB levels were compared among the different demographic subgroups.Detailed findings are presented in Table 4.The KAB of medical staff is not significantly different between positions, titles, and education.

Predictors of medical staff's KAB of dysphagia assessment
In the final regression analysis, all the categorical variables were transformed into dummy variables.

Status of KAB of dysphagia assessment
In our study, the KAB scores were 92.65±17.52,and the percentile rating score was 71.60.The percentile rank was 53.99, which means that 53.99% of participants' KAB scores were above the average score.According to the percentile rating score in Table 2, Knowledge and Behavior scores were medium, and attitude scores were high.This suggests that people are willing to assess swallowing disorders, but lack Knowledge and Behavior.The lack of knowledge in our study is reflected in the following aspects: First, 80.41% and 76.29% participants did not know how to perform the volume-viscosity swallowing test (VVST) and water swallow test, respectively.This is related to the fact that 84.42% of the participants did not have specialized training in geriatric, swallowing, and rehabilitation.Second, nearly half of the participants did not know the concept of mouthful size, food requirements for patients with dysphagia, or how to feed patients with hemiplegia.An audit [17] conducted in our inpatient hospice showed that 57% of nurses followed prescribed dysphagia management.The deficiencies included using the wrong utensils, incorrect positioning of the patient during feeding, or giving patients fluids or food of the wrong consistency.This rate is similar to an informal observation of 50% compliance published by the creator of the Mealtime and Dysphagia Questionnaire (MDQ) [18] .The lack of behavior in our study is mainly reflected in the following aspects.First, in 79.12% of the participants' departments, when stroke patients were screened for dysphagia, no further instrumental examinations were performed.Second, in 13.92% of the participants' departments, swallowing function was not screened in stroke patients after admission.Nurse stress with patient characteristics and workload may affect whether a swallow screen is undertaken [19] .The time of screening or assessment of OD prevalence was recorded.OD prevalence estimates from the hospital setting were reported as the time post-stroke or time from admission.Time post-stroke ranged from the hyperacute phase [20] : ≤24h post-stroke, to the acute phase [21] ; 1-7 days, to the early subacute phase [22] ;7 days-3 months, to the recovery phase [23] .Therefore, we should screen for or assess dysphagia at the right time based on the patient's condition and identify reliable and standardized assessment methods for screening post-stroke dysphagia(PSD) in acute stroke patients to ensure reliable estimates [24] .One study reported that 35.8% of professionals did not know the definition of dysphagia as a swallowing disorder [25] .Lack of knowledge among healthcare professionals can lead to inappropriate practices and increase the complications of dysphagia, such as aspiration pneumonia and malnutrition.This is an important barrier in the management of patients with dysphagia.One study investigated the Knowledge, Attitude and Practice of healthcare providers in Iran, and the results showed that very few participants were familiar with a standard test for screening and assessment of dysphagia (11.9%).A total of 74.7% were willing to participate in a workshop on dysphagia; the main pitfalls in their country lie in practice [26] .Another study reported that there seems to be limited awareness among ICU practitioners that patients are at risk of dysphagia, particularly as ventilation persists, protocols, routine assessment, and instrumental assessments are generally not used [27] .

Comparison of medical staff's KAB in different Provinces
In our study, the KAB of participants in Shaanxi Province was higher than that of participants in other provinces.The reasons for this are as follows.First, 95% of the participants in Shaanxi Province came from neurological, rehabilitation, and elderly related departments that mainly treat patients with stroke.There are many situations in the workplace that require the assessment of swallowing disorders.Second, 87.5% of participants in Shaanxi Province had experience in nursing patients with dysphagia.

Developing training resources by predictors of KAB of dysphagia assessment
There is still plenty of room to improve medical staff's Knowledge, Attitudes and Behavior regarding dysphagia assessment.Multiple linear regression results indicated that experience of dysphagia patients' nursing, related training for dysphagia, working years in the field of dysphagia related diseases, specialized training in geriatric, swallowing & rehabilitation and, neurological, rehabilitation, elderly related department were significant predictors.Consequently, the following countermeasures were proposed: The following countermeasures were based on the theory of Knowledge-Attitude-Practice and Self-efficacy:

Strengthening relevant training to improve Knowledge of dysphagia assessment
Knowledge-attitude-practice (KAP) theory is widely used in behavioral psychology [28] .This theory emphasizes that change in an individual's behavior consists of three continuous processes: acquiring knowledge, establishing beliefs and producing behavior, and paying attention to their causality and progressive relationship.The diagnosis and management of dysphagia requires comprehensive knowledge of diverse etiologies, with a systematic approach for the assessment of symptoms, selection of investigations, and appropriate treatment to relieve symptoms [29] .Meanwhile, staff who provide mealtime assistance to people with dysphagia require adequate training to ensure that mealtimes are safe and enjoyable [30] .In this study, knowledge consisted of an assessment approach, dysphagia symptoms, mealtime assistance, and so on.

Establishing positive belief in assessment of dysphagia
According to KAP theory, beliefs and attitudes are the motive forces for individuals to produce related behaviors [28] .As the results of study, the attitude score of medical staff was 35.89±4.86,which was at the high level.This finding suggests that many people are willing to screen and evaluate patients with dysphagia.This was a good trend.
Nurses gained a sense of value by assessing and caring for patients with dysphagia.Dysphagia screening is often the focus of hospitalized stroke patients; however, dysphagia can also occur in other hospitalized patients and outpatients.Dysphagia can be overlooked by nurses and clinicians, and it is therefore important to educate nurses on the importance of dysphagia screening [31] .

Accumulate dysphagia assessment experience through work and study
Self-efficacy refers to an individual's conviction of their capacity to perform a specific activity.Individuals gain self-efficacy over time as they acquire a range of talents, such as social, cognitive, physical, and linguistic abilities, via life experiences [32] .Efficacy expectations are dynamic and are both appraised and enhanced by four mechanisms [33][34] : (1) enactive mastery experience or successful performance of the activity of interest; (2) verbal persuasion or encouragement, given by a credible source that the individual is capable of performing the activity of interest; (3) vicarious experience or seeing like individuals perform a specific activity; and (4) physiological and affective states such as pain, fatigue, anxiety, hunger, or dizziness associated with a given activity.These mechanisms to drive efficacy expectations are the concepts upon which the intervention is built to encourage behavioral change.In this study, experience of dysphagia patients' nursing, working years in the field of dysphagia related diseases, and neurological, rehabilitation, elderly related department were significant predictors of medical staff's Knowledge, Attitudes and Behavior of dysphagia assessment.The results are consistent with the self-efficacy theory.This suggests that if conditions permit, the medical staff in other departments with no experience of dysphagia patients' nursing should transfer to neurological, rehabilitation, and elderly related departments to be trained and accumulate relevant experience.Alternatively, the hospital organizes regular workshops for dysphagia assessment and nurses are required to participate in practice.

Establish systematic inter-professional collaboration in dysphagia management
A study showed that the main theme "limited professional services" describes how patients received little support from healthcare professionals and had to rely on themselves to adapt to life with dysphagia [35] .The common goal of preventing aspiration and rehabilitating patients' ability to swallow safety is based on dysphagia assessment, using appropriate therapeutic interventions, sharing knowledge, and improving skills among professional groups that consist of nurses, physicians, occupational therapists, and speech-language pathologists(SLPs) [36] .

Conclusions and Implications for future Research
Treatment pathways, including early assessment and diagnosis of dysphagia, should be a priority for healthcare professionals working in different settings with populations at risk for dysphagia.Most studies have focused on medical staff in hospitals, and few have focused on medical staff from nursing home settings, social health service centers, and palliative care facilities.Future studies should focus on the evaluation of dysphagia and provide training for the assessment of swallowing disorders to medical staff in nursing home settings, social health service centers, and palliative care facilities.
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Table 3 . Differences of medical staff 's Knowledge, Attitudes and Behavior of dysphagia assessment in different province(one-way analysis of variance)
***The scores of the questionnaire in Shaanxi province was higher than Guangdong(p=0.002) and Hunan(p<0.001)KAB=Knowledge, Attitudes and Behavior

Table 4 . Differences of medical staff 's Knowledge, Attitudes and Behavior of dysphagia assessment in Sociodemographic, training and working experience characteristics(n=353)
Table 5 presents the dummy variables' settings.Dummy multiple regression analysis was conducted to identify relevant predictors for medical staff KAB in dysphagia assessment.As seen in Table 6, working years in the field of dysphagia related diseases, specialized training in geriatric, swallowing, and rehabilitation; nursing experience of patients with dysphagia; neurological, rehabilitation, elderly related department; and related training for dysphagia were significant predictors of medical staff's KAB of dysphagia assessment, accounting for 35.1% of variance.

Table 6 . Factors related to Knowledge, Attitudes and Behavior by stepwise regression
The mean score of medical staff was 15.34±2.66,whichwasat the middle level, and 49.58% participants had received related training for dysphagia(35.80% in other departments VS 63.28% in neurological, rehabilitation, and elderly related departments).Only 15.58% of the participants had received specialized training in geriatric, swallowing, and rehabilitation(8.52% in other departments VS 22.60% in neurological, rehabilitation, and elderly related departments).Medical staff in neurological, rehabilitation, and elderly related departments seldom receive related training for dysphagia, which leads to less knowledge of assessment or screening for dysphagia.Therefore, it is more difficult for medical staff to establish positive beliefs regarding dysphagia assessment and screening.To standardize the management of dysphagia, hospitals should take the rate of dysphagia assessment as a quality control index and promote training in dysphagia assessment.Examples include the Volume-Viscosity Swallow Test(V-VST), water swallow test, eating assessment Tool-10(EAT-10), and Mann Assessment of Swallowing Ability (MASA)..